Audit Report. Testicular Cancer Quality Performance Indicators. West of Scotland Cancer Network. Urological Cancer Managed Clinical Network

Transcription

1 Urological Cancer Managed Clinical Network Audit Report Testicular Cancer Quality Performance Indicators Clinical Audit Data: 01 October 2014 to 30 September 2015 Mr Gren Oades MCN Clinical Lead Tom Kane MCN Manager Sandie Ker Information Officer

2 CONTENTS EXECUTIVE SUMMARY 3 1. INTRODUCTION 9 2. BACKGROUND NATIONAL CONTEXT WEST OF SCOTLAND CONTEXT METHODOLOGY RESULTS AND ACTION REQUIRED DATA QUALITY PERFORMANCE AGAINST QUALITY PERFORMANCE INDICATORS (QPIS) CONCLUSIONS 26 ACKNOWLEDGEMENT 28 ABBREVIATIONS 29 REFERENCES 30 APPENDIX: NHS BOARD ACTION PLANS 31 Final Published Testicular Cancer MCN Audit Report v1.0 13/06/2016 2

3 Executive Summary Introduction This report contains an assessment of the performance of West of Scotland (WoS) urological cancer services using clinical audit data relating to patients diagnosed with testicular cancer in the twelve months between 01 October 2014 and 30 September Data are collected for all urological cancers, however data analysed and included within this report relates to cancer of the testis only and results are measured against the Testicular Cancer Quality Performance Indicators 1 (QPIs) which were implemented for patients diagnosed on or after 01 October The National Cancer Quality Steering Group (NCQSG) completed a programme of work to develop national QPIs for all cancer types to enable national comparative reporting and drive continuous improvement for patients in In collaboration with the three Regional Cancer Networks and Information Services Division (ISD) the Testicular Cancer QPIs were published by Healthcare Improvement Scotland (HIS) in October Data definitions and measurability criteria to accompany the Testicular Cancer QPIs are available from the ISD website 2. Twelve months of data were measured against the Testicular Cancer QPIs and presented within this audit report. There are no annual comparisons as this is the first year of analysis since implementation of the QPI dataset. Future reports will compare clinical audit data in successive years to illustrate trend analysis. Background Testicular cancer is rare and is the 16 th most commonly diagnosed malignancy in Scottish men with a relative frequency of around 1.2% of all cancers 3. There has been a slight increase in the incidence of testicular cancer in the past ten years from 2003 to 2013 of 0.1% 3. Testicular cancer has the highest survival rates of all cancer types and survival has improved in the 20 years to Mortality rates for testicular cancer have fallen by 37.7% in the past ten years from 2004 to Major advances in the treatment of testicular cancer have contributed towards these improved survival and mortality rates. Four NHS Boards across the WoS serve the 2.46 million population 5. From this population, around 100 new cases of testicular cancer are diagnosed each year. The configuration of the Multidisciplinary Teams (MDTs) in the region is set out below. MDT Ayrshire & Arran (AA) Greater Glasgow and Clyde (GGC) Forth Valley (FV) Lanarkshire (Lan) Constituent Hospitals Crosshouse Hospital, Ayr Hospital (i) Gartnavel General Hospital, Glasgow Royal Infirmary, Queen Elizabeth University Hospital, Vale of Leven (ii) Royal Alexandra Hospital, Inverclyde Royal Hospital Forth Valley Royal Hospital Monklands District General, Wishaw General Hospital, Hairmyres Hospital Final Published Testicular Cancer MCN Audit Report v1.0 13/06/2016 3

4 Methodology The clinical audit data presented in this report was collected by clinical audit staff in each NHS Board in accordance with an agreed dataset and definitions. The data was entered locally into the electronic Cancer Audit Support Environment (ecase): a secure centralised web-based database. Data relating to patients diagnosed between 01 October 2014 and 30 September 2015 was downloaded from ecase on 23 December Analysis was performed centrally by the (WoSCAN) Information Team and the timescales agreed took into account the patient pathway to ensure that a complete treatment record was available for each case. Initial results of the analysis were provided to local NHS Boards to check for inaccuracies or obvious gaps before final analysis was carried out. Final results were disseminated for NHS Board verification in line with the regional audit governance process, to ensure that the data was an accurate representation of service in each area. Results Case ascertainment is an estimate of the proportion of expected patients identified through audit. Case ascertainment for testicular cancer is relatively low across WoS at 71.9% which may indicate not all cases have been captured by audit. It should however be noted that the predicted incidence of all cancer types is based on historic numbers of cases diagnosed and therefore some variation in case ascertainment is expected. Overall data capture is excellent and there were no data fields missing which are required for accurate measurement of individual QPIs. Results for each QPI are shown in detail in the main report and illustrate NHS Board performance against each target and overall WoS performance for each performance indicator. Results are presented graphically and the accompanying tabular format also highlights any missing data and its possible effect on any of the measured outcomes. The summary of results overpage shows the WoS percentage performance against each QPI target and performance by NHS Board. All four NHS Boards met the QPI target for QPIs 2, 4, 5, 7 and 10 (i), 10(ii) and 10(iii). There are no year-on-year comparisons as this is the first year of reporting against Testicular Cancer QPIs. Targets for QPIs 1, 3, 6 and 8 proved more challenging to meet. Final Published Testicular Cancer MCN Audit Report v1.0 13/06/2016 4

5 TESTICULAR QPI Quality Performance Indicators Performance by NHS Board/Region QPI target WoS AA FV GGC LAN 1. Radiological Staging - Patients with testicular cancer should be evaluated with appropriate imaging to detect the extent of disease and guide treatment decision making. 95% 89.1% N:57 D: % N:12 D: % N:5 D:8 97.1% N: 33 D: % N:7 D:9 2. Pre-operative Assessment - Patients with testicular cancer should have pre-operative assessment of the testicle and Serum Tumour Markers (STMs). 95% 98.4% N:63 D:64 N:13 D:13 N:8 D:8 97.1% N:33 D:34 N:9 D:9 3. Primary Orchidectomy - Patients with testicular cancer should have primary orchidectomy within 2 weeks of ultrasonographic diagnosis. 95% 52.3% N:34 D: % N:12 D: % N:2 D:8 36.1% N:13 D: % N:7 D:8 4. Multi-Disciplinary Team Meeting - Patients with testicular cancer should be discussed by a Multidisciplinary Team (MDT) to agree a definitive management plan post orchidectomy with staging and pathology. 95% 98.5% N:66 D:67 N:13 D:13 N:8 D:8 97.3% N:36 D:37 N:9 D:9 5. Pathology Reporting - All pathology reports for testicular cancer should contain full pathology information to inform patient management. 90% 98.5% N:66 D:67 N:13 D:13 N:8 D:8 97.3% N:36 D:37 N:9 D:9 6. Adjuvant Treatment of Stage I Seminoma with Carboplatin - Patients with stage I seminoma receiving adjuvant single dose carboplatin should have an AUC of 7mg/ml/min based on ethylene diamine tetra-acetic acid (EDTA) clearance. 95% 63.2% N:12 D:19 N:6 D:6-66.7% N:6 D:9 - Meets/exceeds QPI target Does not meet QPI target N: Numerator D: Denominator (-) dash denotes a denominator of less than 5. Figures have been removed to ensure confidentiality.

6 TESTICULAR QPI Quality Performance Indicators Performance by NHS Board/Region QPI target WoS AA FV GGC LAN 7. Serum Tumour Markers - Patients with metastatic testicular cancer should undergo Serum Tumour Markers (STMs)* before starting chemotherapy to determine their correct International Germ Cell Cancer Collaborative Group (IGCCCG) prognostic grouping. 98% N:18 D: N:8 D:8-8. Systemic Therapy - Patients with metastatic testicular cancer who are undergoing systemic therapy should receive Systemic Anti-Cancer Therapy (SACT) within 3 weeks of a MDT decision to treat with SACT. 95% 83.3% N:15 D: % N:6 D:8-9. Computed Tomography Scanning for Surveillance Patients - Patients with stage I testicular non seminomatous (or mixed) germ cell tumour (NSGCT) under surveillance should undergo CT scanning of the abdomen +/- chest and pelvis, as per clinical relevance. 85% Not reported until year 2, as 14 months needs to elapse from the diagnosis date 10(i). 30 Day Mortality - 30 day mortality following treatment for testicular cancer - Orchidectomy <5% 0.0% N:0 D:67 0.0% N:0 D:13 0.0% N:0 D:8 0.0% N:0 D:38 0.0% N:0 D:8 10(ii). 30 Day Mortality - 30 day mortality following treatment for testicular cancer Chemotherapy <5% 0.0% N:0 D:49 0.0% N:0 D:12 0.0% N:0 D:5 0.0% N:0 D:26 0.0% N:0 D:6 10(iii). 30 Day Mortality - 30 day mortality following treatment for testicular cancer Radiotherapy <5% 0.0% N:0 D: Meets/exceeds QPI target Does not meet QPI target N: Numerator D: Denominator (-) dash denotes a denominator of less than 5. Figures have been removed to ensure confidentiality. Final Published Testicular Cancer MCN Audit Report v1.0 13/06/2016 6

7 Conclusions and Action Required Cancer audit has underpinned much of the regional development and service improvement work of the MCN and the regular reporting of activity and performance have been fundamental in assuring the quality of care delivered across the region. With the development of Quality Performance Indicators, this has now become a national programme to drive continuous improvement and ensure equity of care for patients across Scotland. West of Scotland Boards commitment in the past few years to the continuous improvement of the quality and completeness of audit data has supported this transition to national reporting. The improvements have provided accurate baseline data for the first year of Testicular Cancer QPIs from which yearly comparisons in the service provision across WoS Boards can be made. Data completeness is particularly high for Testicular Cancer QPIs with the 11 reported QPIs having all relevant data fields completed. It should be noted however that case ascertainment is low in some Boards and should be investigated further. Overall, results from the first year of Testicular Cancer QPI analysis are encouraging with 7 of the 11 reported QPIs being met by all four NHS Boards. It is evident however that NHS Boards have found some QPI targets challenging to meet. The audit report has identified actions relating to service provision especially with regard to timescales within the patient pathway. Specifically, the time from ultrasound diagnosis to orchidectomy and the time from orchidectomy to CT scanning require improvement to meet QPI targets. All actions are summarised overpage and are outlined in the main report under the relevant section. NHS Boards are asked to develop local Action/Improvement Plans in response to the findings presented in the report. Action required: Data Quality: NHS Lanarkshire and NHSGGC should compare the cases captured by audit directly with cancer registry data once this becomes available to identify whether any new cases of testicular cancer have not been included in Year 1 QPI audit. QPI 1 Radiological staging NHS Forth Valley should monitor outcome following meeting between clinical team and patient pathway co-ordinators. NHS Lanarkshire should continue to monitor improvements following the implementation of the direct referral pathway. QPI 3 Primary Orchidectomy NHSGGC should review cases where the time from ultrasound diagnosis to surgery exceeds 14 days to identify issues which may be causing delay and take appropriate action. NHS Forth Valley should monitor results locally to ensure the actions implemented with regard to GP referral have shown improved performance. QPI 6 Adjuvant treatment of stage I seminoma with carboplatin NHSGGC should review pathways to ensure all patients undergoing adjuvant single-dose carboplatin AUC7 have an EDTA carried out and commence treatment within 8 weeks of orchidectomy.

8 QPI 8 Systemic Therapy NHSGGC should review cases to determine any potential issues in meeting the QPI criteria for QPI 8 and take appropriate action. A summary of actions for each NHS Board has been included within the Action Plan templates in the Appendix. Completed Action Plans should be returned to WoSCAN within two months of publication of this report. Progress against these plans will be monitored by the MCN Advisory Board and any service or clinical issue which the Advisory Board considers not to have been adequately addressed will be escalated to the NHS Board Territorial Lead Cancer Clinician and Regional Lead Cancer Clinician. Additionally, progress will be reported annually to the Regional Cancer Advisory Group (RCAG) by NHS Board Territorial Lead Cancer Clinicians and MCN Clinical Leads, and nationally on a threeyearly basis to Healthcare Improvement Scotland as part of the governance processes set out in CEL 06 (2012). Final Published Testicular Cancer MCN Audit Report v1.0 13/06/2016 8

9 1. Introduction This report contains an assessment of the performance of West of Scotland (WoS) urological cancer services using clinical audit data relating to patients diagnosed with testicular cancer in the twelve months between 01 October 2014 and 30 September Regular reporting of activity and performance is a fundamental requirement of a Managed Clinical Network (MCN) to assure the quality of care delivered across the region. Data are collected for all urological cancers, however data analysed and included within this report relates to cancer of the testis. Results are measured against the Testicular Cancer Quality Performance Indicators 1 (QPIs) which were introduced for patients diagnosed on or after 01 October 2014, and Testicular Cancer QPIs are reported here for the first year of data collection. The National Cancer Quality Steering Group (NCQSG) completed a programme of work to develop national QPIs for all cancer types to enable national comparative reporting and drive continuous improvement for patients in In collaboration with the three Regional Cancer Networks and Information Services Division (ISD) the Testicular Cancer QPIs were published by Healthcare Improvement Scotland (HIS) in October Data definitions and measurability criteria to accompany the testicular cancer QPIs are available from the ISD website 2. Twelve months of data are measured against the Testicular Cancer QPIs and presented within this audit report. There are no annual comparisons as this is the first year of analysis since implementation of the QPI dataset. Future reports will compare clinical audit data in successive years to illustrate trend analysis. 2. Background Four NHS Boards across the WoS serve the 2.47 million population 5. There were 69 patients diagnosed with testicular cancer in the WoS between 01 October 2014 and 30 September The configuration of the Multidisciplinary Teams (MDTs) in the region is set out below and each MDT convenes on a weekly basis. MDT Ayrshire & Arran (AA) Greater Glasgow and Clyde (GGC) Forth Valley (FV) Lanarkshire (Lan) Constituent Hospitals Crosshouse Hospital, Ayr Hospital (i) Gartnavel General Hospital, Glasgow Royal Infirmary, Queen Elizabeth University Hospital, Vale of Leven (ii) Royal Alexandra Hospital, Inverclyde Royal Hospital Forth Valley Royal Hospital Monklands District General, Wishaw General Hospital, Hairmyres Hospital Final Published Testicular Cancer MCN Audit Report v1.0 13/06/2016 9

10 2.1 National Context Testicular cancer is the 16 th most common cancer in males with approximately 200 cases diagnosed in Scotland each year between 2009 and The incidence of testicular cancer has increased slightly in the past ten years from 2003 to 2013 by 0.1% 3. Relative survival for testicular cancer is increasing 4 and testicular cancer has the highest survival rates compared to any other cancer type with a 1-year relative survival of 99.4% and a 5-year relative survival of 98.7% 3 ( ). Table 1 shows the percentage change in 1-year and 5-year agestandardised survival rates for patients diagnosed with testicular cancer in compared to those diagnosed in Survival rates are age-standardised to allow fair comparison over time. Major advances in surgical, chemotherapy and radiotherapy treatments for testicular cancer have contributed to the high survival rates observed 4, 7. Mortality rates have decreased by 37.7% in the last ten years from 2004 to Table 1: Relative age-standardised survival for testicular cancer in Scotland at 1 year and 5 years showing percentage change from to Relative survival at 1 year (%) Relative survival at 5 years (%) % change % change Testicular Cancer 95.9 % % 91.1 % % 2.2 West of Scotland Context A total of 69 cases of testicular cancer were recorded through audit as diagnosed in the West of Scotland between 01 October 2014 and 30 September The number and percentage of patients diagnosed within each NHS Board is presented in Figure 1. As the largest WoS Board, 53.6% of all new cases of testicular cancer were diagnosed in NHS Greater Glasgow and Clyde (NHSGGC) which is slightly higher than population estimates for this Board (46.3% of WoS population, 2014 mid-year estimates 5 ). Figure 1: Proportion of WoS patients diagnosed with testicular cancer within each NHS Board, Oct 14 to Sept 15. Lan 14.5% AA 20.3% GGC 53.6% FV 11.6% AA FV GGC Lan N % N % N % N % WoS Total Testicular cancer % % % % 69 Final Published Testicular Cancer MCN Audit Report v1.0 13/06/

11 The majority of men diagnosed with testicular cancer are in the younger age groups with more than half of all new diagnoses occurring in males under 40 years old. Figure 2 illustrates the distribution of the number of new diagnoses within each age group for the WoS. Figure 2: Number of patients diagnosed with testicular cancer in WoS within each age group, Oct 14 to Sept 15. Number of patients Age group (years) Age group No. of patients Methodology The clinical audit data presented in this report was collected by clinical audit staff in each NHS Board in accordance with an agreed dataset and definitions. The data was recorded manually and entered locally into the electronic Cancer Audit Support Environment (ecase): a secure centralised webbased database. Data relating to patients diagnosed between 01 October 2014 and 30 September 2015 was downloaded from ecase at 2200 hrs on 23 December Cancer audit is a dynamic process with patient data continually being revised and updated as more information becomes available. This means that apparently comparable reports for the same time period and cancer site may produce slightly different figures if extracted at different times. Analysis was performed centrally for the region by the (WoSCAN) Information Team and the timescales agreed took into account the patient pathway to ensure that a complete treatment record was available for each case. Initial results of the analysis were provided to local NHS Boards to check for inaccuracies, inconsistencies or obvious gaps and a subsequent download taken upon which final analysis was carried out. The final data analysis was disseminated for NHS Board verification in line with the regional audit governance process to ensure that the data was an accurate representation of service in each area. Final Published Testicular Cancer MCN Audit Report v1.0 13/06/

12 4. Results and Action Required 4.1 Data Quality Audit data quality can be assessed in the first instance by estimating the proportion of expected patients that have been identified through audit. Case ascertainment is calculated as the number of new cases identified by the audit as a proportion of the number of cases reported by the National Cancer Registry (provided by Information Services Division, National Services Scotland). Cancer Registry figures were extracted from ACaDMe (Acute Cancer Deaths and Mental Health), a system provided by Information Services Division (ISD). Cancer Registry figures are an average of the previous five years figures to take account of annual fluctuations in incidence within NHS Boards. Figure 3: Case ascertainment by NHS Board for patients diagnosed with testicular cancer, Oct 14 to Sept % Case ascertainment (%) 80% 70% 60% 50% 40% 30% 20% 10% 0% AA FV GGC Lan WoS NHS Board of diagnosis AA FV GGC Lan WoS Cases from audit ISD Cases ( average) % Case ascertainment 88.9% 69.8% 52.6% 71.9% Overall case ascertainment for WoS is relatively low at 71.9% which may indicate that not all cases have been captured through audit. Case ascertainment figures however are provided for guidance and are not an exact measurement as it is not possible to compare directly with the same cohort. Lower figures can also indicate decreasing incidence of a particular cancer type within a board or region. Case ascertainment for each WoS Board is illustrated in Figure 3. There is variation in percentage case ascertainment across the four NHS Boards ranging from 52.6% in NHS Lanarkshire to in NHS Ayrshire & Arran. NHS Lanarkshire and NHSGGC should compare the cases captured by audit to cancer registry data once this becomes available to identify whether any new cases of testicular cancer have not been included in audit figures. For each of the 11 reported Testicular Cancer QPIs, all the relevant data items had values recorded (i.e. for numerator, denominator or exclusions) and therefore the information presented within this report is of high accuracy. Action Required: NHS Lanarkshire and NHSGGC should compare the cases captured by audit to cancer registry data to identify whether any new cases of testicular cancer have not been included. Final Published Testicular Cancer MCN Audit Report v1.0 13/06/

13 4.2 Performance against Quality Performance Indicators (QPIs) Results of the analysis of Testicular Cancer Quality Performance Indicators (QPIs 1 8, and 10) are set out in the following sections. Graphs and charts have been provided where this aids interpretation and, where appropriate, numbers have also been included to provide context. Data (both graphically and in tabular format) are presented by location of diagnosis, location of treatment, or by operating surgeon, with some criteria given as an overall West of Scotland representation. Specific regional and NHS Board actions have been identified to address issues highlighted through the data analysis. Where the number of cases meeting the denominator criteria for any indicator is between one and four, the percentage calculation has not been shown on any associated charts or tables. This is to avoid any unwarranted variation associated with small numbers and to minimise the risk of disclosure. Any charts or tables impacted by this are denoted with a dash (-). Any commentary provided by NHS Boards relating to the impacted indicators will however be included as a record of continuous improvement. Final Published Testicular Cancer MCN Audit Report v1.0 13/06/

14 QPI 1: Radiological Staging Patients with testicular cancer should be evaluated with appropriate imaging to detect the extent of disease and guide treatment decision making. Timely imaging is important to ensure treatment decision making can occur as soon as possible 1. Unnecessary delays can have an impact on prognostic groups and hence survival rates. Computed Tomography (CT) scanning is an essential part of the staging of all germ cell tumours 1. Description: Numerator: Denominator: Proportion of patients with testicular cancer who undergo Computed Tomography (CT) scanning, ideally contrast-enhanced CT, of the chest, abdomen and pelvis within 3 weeks of orchidectomy. Number of patients with testicular cancer undergoing CT scanning of the chest, abdomen and pelvis within 3 weeks of orchidectomy. All patients with testicular cancer. Exclusions: Patients undergoing chemotherapy prior to orchidectomy. Target: 95% Figure 4: The proportion of patients with testicular cancer who undergo CT scanning of the chest, abdomen and pelvis within three weeks of orchidectomy. QPI target - 95% 90% Proportion of patients (%) 80% 70% 60% 50% 40% 30% 20% 10% 0% AA FV GGC Lan WoS NHS Board QPI 1 Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 92.3% % 0 0.0% 0 FV 62.5% % 0 0.0% 0 GGC 97.1% % 0 0.0% 0 Lan 77.8% % 0 0.0% 0 WoS 89.1% % 0 0.0% 0 Of the 64 patients diagnosed with testicular cancer in Year 1 of QPI analysis, 57 patients underwent CT scanning within 3 weeks of orchidectomy resulting in a WoS performance of 89.1% against the 95% QPI target. NHSGGC met the 95% target for QPI 1 with a performance of 97.1%, as 33 of 34 patients within NHSGGC had a CT scan performed within 3 weeks of orchidectomy. Final Published Testicular Cancer MCN Audit Report v1.0 13/06/

15 NHS Forth Valley, NHS Lanarkshire and NHS Ayrshire & Arran did not meet the QPI target with performance of 62.5%, 77.8% and 92.3% respectively; although small numbers should be noted in these three NHS Boards which can result in fluctuating percentages year to year or large differences between NHS Boards, even when differences are not necessarily meaningful. Within NHS Forth Valley, 3 of 8 patients did not meet the QPI criteria. All patients did undergo CT as recommended though the scan was delayed in 3 cases. NHS Forth Valley has commented that a meeting between the clinical team and patient pathway co-ordinators is required to ensure scans are prioritised appropriately. In NHS Lanarkshire, 2 of 9 patients did not meet the QPI criteria. One patient had a CT scan at 23 days and the other at 29 days post orchidectomy. NHS Lanarkshire commented that a direct referral policy to on-call urology team has now been implemented and a marked improvement in a short time scale has been noted. Within NHS Ayrshire & Arran, 1 of 13 patients did not meet the QPI criteria. Comments received stated that the patient had a CT scan at 3 weeks and 2 days post orchidectomy. Action Required: NHS Forth Valley should monitor outcome following meeting between clinical team and patient pathway co-ordinators. NHS Lanarkshire should continue to monitor improvements following the implementation of the direct referral pathway. QPI 2: Pre-operative Assessment Patients with testicular cancer should have pre-operative assessment of the testicle and Serum Tumour Markers (STMs). In most instances, the diagnosis of testicular tumours is established with a carefully performed physical examination and scrotal ultrasound 1. When conducting pre-operative assessments, evidence has demonstrated the importance of investigating STM concentrations and conducting a testicular ultrasound. Serum determination of tumour markers before and after orchidectomy allow for staging and prognosis to be determined 1. Description: Numerator: Denominator: Proportion of patients with testicular cancer who undergo preoperative assessment of the testicle which, at a minimum, includes: (i) STMs*, and (ii) testicular ultrasound. Number of patients with testicular cancer undergoing orchidectomy, who undergo a preoperative assessment of the testicle which, at a minimum, includes: (i) STMs*, and (ii) testicular ultrasound. All patients with testicular cancer undergoing orchidectomy. Exclusions: Patients who refuse to undergo assessment. Patients undergoing chemotherapy prior to orchidectomy. Target: 95% * AFP Alpha-fetoprotein, HCG Human chorionic gonadotropin, LDH Lactate dehydrogenase Final Published Testicular Cancer MCN Audit Report v1.0 13/06/

16 Figure 5: The proportion of patients with testicular cancer who underwent preoperative assessment of the testicle (STMs and testicular ultrasound). QPI target - 95% 90% Proportion of patients (%) 80% 70% 60% 50% 40% 30% 20% 10% 0% AA FV GGC Lan WoS NHS Board QPI 2 Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA % 0 0.0% 0 FV % 0 0.0% 0 GGC 97.1% % 0 0.0% 0 Lan % 0 0.0% 0 WoS 98.4% % 0 0.0% 0 Of the 64 patients that were diagnosed with testicular cancer that underwent orchidectomy in Year 1 (minus exclusions), 63 patients underwent a preoperative assessment of the testicle which included Serum Tumour Markers (STMs) and testicular ultrasound. This resulted in a WoS performance of 98.4% against the 95% QPI target. All four NHS Boards met the target for QPI 2 with NHS Ayrshire & Arran, NHS Forth Valley and NHS Lanarkshire all achieving. QPI 3: Primary Orchidectomy Patients with testicular cancer should have primary orchidectomy within 2 weeks of ultrasonographic diagnosis. Orchidectomy is the primary therapeutic intervention for patients who have early-stage testicular cancer. The overall aim of primary orchidectomy is to remove the tumour and minimise local recurrence and abnormal lymphatic spread 1. To ensure pathological information is obtained and future treatment decision making can be made, it is important that orchidectomy is carried out as quickly as possible from diagnosis 1. Description: Proportion of patients with testicular cancer who undergo primary orchidectomy within 2 weeks of ultrasonographic diagnosis. Numerator: Denominator: Number of patients with testicular cancer undergoing orchidectomy within 2 weeks of ultrasonographic diagnosis. All patients with testicular cancer undergoing orchidectomy. Exclusions: Patients undergoing chemotherapy prior to orchidectomy. Target: 95% Final Published Testicular Cancer MCN Audit Report v1.0 13/06/

17 Figure 6: The proportion of patients with testicular cancer who underwent primary orchidectomy within two weeks of ultrasonographic diagnosis. QPI target - 95% 90% Proportion of patients (%) 80% 70% 60% 50% 40% 30% 20% 10% 0% AA FV GGC Lan WoS NHS Board QPI 3 Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 92.3% % 0 0.0% 0 FV 25.0% % 0 0.0% 0 GGC 36.1% % 0 0.0% 0 Lan 87.5% % 0 0.0% 0 WoS 52.3% % 0 0.0% 0 Of the 65 patients diagnosed with testicular cancer undergoing orchidectomy (minus exclusions), 34 patients underwent surgery within two weeks of ultrasound diagnosis. This resulted in an overall WoS performance of 52.3% against the 95% QPI target. None of the four NHS Boards met the 95% target and performance varied significantly between Boards ranging from 25.0% in NHS Forth Valley to 92.3% in NHS Ayrshire & Arran. A funnel plot of results showed NHS Lanarkshire and NHS Ayrshire & Arran to have significantly higher performance when compared to the WoS average (52.3%) and NHSGGC to have significantly lower than average performance. NHS Forth Valley results were just within 2 standard deviations of the mean and were therefore not found to be significantly lower than the WoS average. NHS Ayrshire & Arran has provided appropriate clinical reason as to why one patient did not meet the QPI criteria. NHS Forth Valley has commented that delay in the 6 cases that did not meet the QPI criteria was due to GP referral to ultrasound scan without appropriate referral through the cancer pathway, thus causing delay to orchidectomy. This has been actioned and GPs in NHS Forth Valley have been advised to refer patients through the suspected cancer pathway at the same time as referring the patient for ultrasound. NHS Lanarkshire had only one case not meeting this QPI due to slight delay in time to orchidectomy. NHS Lanarkshire has commented that the direct referral policy implemented should improve the time scales to meet this QPI. NHSGGC had 23 cases not meeting the QPI criteria; one case did not have an ultrasound date recorded, however date of surgery was equal to the date of diagnosis. The remaining 22 cases all had surgery following ultrasound but outwith the two-week period stipulated by the QPI criteria. Final Published Testicular Cancer MCN Audit Report v1.0 13/06/

18 Overall in WoS, further analysis has shown that for all patients included in the denominator for QPI 3, the median number of days from date of ultrasound to date of surgery is 12.5 days. Table 2 below shows the median and mean number of days to surgery for patients who (i) met the QPI criteria, (ii) did not meet the QPI criteria and (iii) all patients. The total number of patients is 64 as one case does not have ultrasound date recorded. Table 2: The median and mean number of days from date of ultrasound diagnosis to date of surgery for patients with testicular cancer who underwent primary orchidectomy. MET (n=34) DID NOT MEET (n=30) ALL PATIENTS (n=64) Median (days) Mean (days) There was discussion at the recent National Urology Meeting and the Testicular Cancer QPI Baseline Review meeting regarding the variable performance across Boards for QPI 3. Issues identified which could be contributing to delayed surgery included patient fitness for orchidectomy, patient availability or the requirement for presurgical semen storage. It was also felt that competing pressure with surgical list organisation was a factor. At the Testicular QPI Baseline Review meeting it was agreed that the target should remain at 95% to drive service improvement as it was considered important that patients should be treated within two weeks of diagnosis. Action Required: NHSGGC should review cases where the time from ultrasound diagnosis to surgery exceeds 14 days to identify issues which may be causing delay and take appropriate action. NHS Forth Valley should monitor results locally to ensure the actions implemented with regard to GP referral have shown improved performance. QPI 4: Multidisciplinary Team Meeting (MDT) Patients with testicular cancer should be discussed by a multidisciplinary team to agree a definitive management plan post orchidectomy with staging and pathology. Orchidectomy can be used as a diagnostic tool as well as definitive treatment for patients with testicular cancer 1. It is important to have the information that is gained from this procedure available at the MDT meeting to ensure a fully informed decision, including tumour type, prognosis and risk factors, can be made on the best management plan for the patient 1. Description: Numerator: Denominator: Proportion of patients with testicular cancer who are discussed at an MDT meeting to agree a definitive management plan post orchidectomy. Number of patients with testicular cancer undergoing orchidectomy who are discussed at the MDT to agree a definitive management plan post orchidectomy. All patients with testicular cancer undergoing orchidectomy. Exclusions: None Target: 95% Final Published Testicular Cancer MCN Audit Report v1.0 13/06/

19 Figure 7: The proportion of patients with testicular cancer who were discussed at an MDT meeting to agree a definitive management plan post orchidectomy. QPI target - 95% 90% Proportion of patients (%) 80% 70% 60% 50% 40% 30% 20% 10% 0% AA FV GGC Lan WoS NHS Board QPI 4 Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA % 0 0.0% 0 FV % 0 0.0% 0 GGC 97.3% % 0 0.0% 0 Lan % 0 0.0% 0 WoS 98.5% % 0 0.0% 0 Of the 67 patients that were diagnosed with testicular cancer that underwent orchidectomy in Year 1, 66 patients were discussed by a multidisciplinary team to agree a definitive management plan post orchidectomy with staging and pathology. This resulted in a WoS performance of 98.5% against the 95% QPI target. All four NHS Boards met the target for QPI 4 with NHS Ayrshire & Arran, NHS Forth Valley and NHS Lanarkshire each achieving. QPI 5: Pathology Reporting Patients with testicular cancer should be discussed by a multidisciplinary team to agree a definitive management plan post orchidectomy with staging and pathology. Orchidectomy can be used as a diagnostic tool as well as definitive treatment for patients with testicular cancer 1. It is important to have the information that is gained from this procedure (including tumour type, prognosis and risk factors) available at the MDT meeting to ensure a fully informed decision can be made on the best management plan for the patient 1. Description: Numerator: Denominator: Proportion of patients with testicular cancer undergoing orchidectomy where the pathology report contains tumour type and size, vascular invasion and rete stromal invasion (based upon the current Royal College of Pathologists dataset). Number of patients with testicular cancer undergoing orchidectomy where histological pathology report contains tumour type and size, vascular invasion and rete stromal invasion. All patients with testicular cancer undergoing orchidectomy. Exclusions: None Target: 90% Final Published Testicular Cancer MCN Audit Report v1.0 13/06/

20 Figure 8: The proportion of patients with testicular cancer undergoing orchidectomy where the pathology report contains tumour type and size, vascular invasion and rete stromal invasion. QPI target - 90% 90% Proportion of patients (%) 80% 70% 60% 50% 40% 30% 20% 10% 0% AA FV GGC Lan WoS NHS Board QPI 5 Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA % 0 0.0% 0 FV % 0 0.0% 0 GGC 97.3% % 0 0.0% 0 Lan % 0 0.0% 0 WoS 98.5% % 0 0.0% 0 Of the 67 patients that were diagnosed with testicular cancer that underwent orchidectomy in Year 1, 66 patients pathology report contained information on tumour type and size, vascular invasion and rete stromal invasion (based upon the current Royal College of Pathologists dataset). This resulted in a WoS performance of 98.5% against the 90% QPI target. All four NHS Boards met the target for QPI 5 with NHS Ayrshire & Arran, NHS Forth Valley and NHS Lanarkshire each achieving. QPI 6: Adjuvant treatment of stage I seminoma with carboplatin Patients with stage I seminoma receiving adjuvant single dose carboplatin should have an AUC (Area Under the Curve) of 7mg/ml/min based on ethylene diamine tetra-acetic acid (EDTA) clearance 1. Evidence has shown that the administration of carboplatin can prevent metastatic relapse and contralateral cancer in patients with testicular cancer 1. Description: Numerator: Denominator: Proportion of patients with stage I seminoma receiving adjuvant single dose carboplatin AUC of 7mg/ml/min (AUC7), based on EDTA clearance within 8 weeks of orchidectomy. Number of patients with stage I seminoma receiving adjuvant single dose carboplatin AUC7, based on EDTA clearance within 8 weeks of orchidectomy. All patients with stage I seminoma undergoing adjuvant single dose carboplatin AUC7. Exclusions: Patients who are treated within a clinical trial. Target: 95% Final Published Testicular Cancer MCN Audit Report v1.0 13/06/

21 Figure 9: The proportion of patients with stage I seminoma receiving adjuvant single dose carboplatin AUC7 based on EDTA clearance, within 8 weeks of orchidectomy. QPI target - 95% Proportion of patients (%) 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% - - AA FV GGC Lan WoS NHS Board QPI 6 Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA % 0 0.0% 0 FV % 0 0.0% 0 GGC 66.7% % 0 0.0% 0 Lan % 0 0.0% 0 WoS 63.2% % 0 0.0% 0 (-) Data is not shown where the denominator is less than 5. Of the 19 patients with stage I seminoma receiving adjuvant single-dose carboplatin (AUC7), 12 patients received chemotherapy treatment within 8 weeks of orchidectomy. This resulted in a WoS performance of 63.2% against the 95% QPI target. Only NHS Ayrshire & Arran met the target for QPI 5 and achieved with 6 of 6 cases meeting the QPI criteria. NHSGGC achieved 66.7% against the 95% target with 6 of 9 cases meeting the QPI criteria. NHS Forth Valley and NHS Lanarkshire both had a denominator of less than 5 and therefore results are not shown above due to the effect small numbers have on percentages. Action Required: NHSGGC should review pathways to ensure all patients undergoing adjuvant single-dose carboplatin AUC7 have an EDTA carried out and commence treatment within 8 weeks of orchidectomy. Final Published Testicular Cancer MCN Audit Report v1.0 13/06/

22 QPI 7: Serum Tumour Markers Patients with metastatic testicular cancer should undergo Serum Tumour Markers (STMs) before starting chemotherapy to determine their correct International Germ Cell Cancer Collaborative Group (IGCCCG) prognostic grouping. Advanced testicular cancer studies have shown that it is beneficial to measure STMs pre-chemotherapy 1. The value of this is to allow for appropriate treatment planning for patients with elevated STMs. Monitoring of STMs can indicate whether the treatment is working or whether a more intensive course of treatment is needed 1. Description: Numerator: Denominator: Proportion of patients with metastatic testicular cancer who undergo STMs 2 weeks before starting chemotherapy. Number of patients with metastatic testicular cancer undergoing chemotherapy who have STMs checked 2 weeks before starting chemotherapy. All patients with metastatic testicular cancer undergoing chemotherapy. Exclusions: None. Target: 98% Figure 10: The proportion of patients with metastatic testicular cancer who undergo STMs 2 weeks before starting chemotherapy. QPI target - 98% Proportion of patients (%) 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% AA FV GGC Lan WoS NHS Board QPI 7 Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA % 0 0.0% 0 FV % 0 0.0% 0 GGC % 0 0.0% 0 Lan % 0 0.0% 0 WoS % 0 0.0% 0 (-) Data is not shown where the denominator is less than 5. Of the 18 patients diagnosed with metastatic testicular cancer undergoing chemotherapy, all 18 patients underwent Serum Tumour Markers (STMs) two weeks before starting chemotherapy, resulting in an overall WoS performance of against the 98% target. Actual numbers are not shown for NHS Ayrshire & Arran, NHS Forth Valley and NHS Lanarkshire as all three Boards have a denominator of less than 5, and percentages will therefore be susceptible to large annual fluctuation. Final Published Testicular Cancer MCN Audit Report v1.0 13/06/

23 QPI 8: Systemic Therapy Patients with metastatic testicular cancer who are undergoing systemic therapy should receive Systemic Anti-Cancer Therapy (SACT) within 3 weeks of an MDT decision to treat with SACT. Evidence has demonstrated that delays in diagnosis and treatment can have a negative impact on the survival rates of patients 1. In certain types of testicular cancer this can have a bigger impact on prognosis and survival 1. Description: Numerator: Denominator: Proportion of patients with metastatic testicular cancer who undergo SACT within 3 weeks of an MDT decision to treat with SACT. Number of patients with metastatic testicular cancer undergoing SACT within 3 weeks of an MDT decision to treat with SACT. All patients with metastatic testicular cancer undergoing SACT. Exclusions: Patients whose primary chemotherapy management is as part of a chemotherapy clinical trial. Target: 95% Figure 11: The proportion of patients with metastatic testicular cancer who undergo SACT within 3 weeks of an MDT decision to treat with SACT. QPI target - 95% Proportion of patients (%) 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% AA FV GGC Lan WoS NHS Board QPI 8 Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA % 0 0.0% 0 FV % 0 0.0% 0 GGC 75.0% % 0 0.0% 0 Lan % 0 0.0% 0 WoS 83.3% % 0 0.0% 0 (-) Data is not shown where the denominator is less than 5. Of the 18 patients diagnosed with metastatic testicular cancer undergoing SACT, 15 patients were started on therapy within 3 weeks of an MDT decision to treat with SACT. This resulted in an overall WoS performance of 83.3% against the 95% QPI target. NHS Ayrshire & Arran, NHS Forth Valley and NHS Lanarkshire each had a denominator of less than 5 and therefore results are not shown above. NHSGGC achieved 75.0% against the 95% target with 6 of 8 patients meeting the QPI criteria, however small numbers should also be noted in this Board which may result in insubstantial year-onyear variation in percentage performance. Final Published Testicular Cancer MCN Audit Report v1.0 13/06/

24 Action Required: NHSGGC should review cases to determine any potential issues in meeting the QPI criteria for QPI 8 and take appropriate action. QPI 9: Computed Tomography Scanning for Surveillance Patients Patients with stage I testicular non-seminomatous (or mixed) germ cell tumour (NSGCT) under surveillance should undergo Computed Tomography (CT) scanning of the abdomen +/- chest and pelvis, as per clinical relevance. There are several ways to manage patients with stage I NSGCT; active surveillance is a standard approach to take 1. Evidence has shown that the results from surveillance are as favourable as those who undertake adjuvant therapy 1. Description: Numerator: Denominator: Proportion of patients with stage I testicular NSGCT (or mixed) under surveillance who undergo at least three CT scans of the abdomen +/- chest and pelvis within 14 months of diagnosis. Number of patients with stage I testicular NSGCT (or mixed) under surveillance who undergo at least three CT scans of the abdomen +/- chest and pelvis within 14 months of diagnosis. All patients with stage I testicular non-seminomatous (or mixed) germ cell tumour. Exclusions: Patients who have received adjuvant chemotherapy. Patients who are treated within a clinical trial. Target: 85% In order to ensure that a full 14-month period has elapsed, enabling accurate measurement, this QPI will be not be reported in year 1, rather year 1 data will be included within year 2 data report. This will ensure accurate and appropriate reporting against this QPI. Final Published Testicular Cancer MCN Audit Report v1.0 13/06/

25 QPI 10: 30-Day Mortality Treatment-related mortality is a marker of the quality and safety of the whole service provided by the multidisciplinary team (MDT) 1. Outcomes of treatment, including treatment-related morbidity and mortality, should be regularly assessed. Treatment should only be undertaken in individuals that may benefit from that treatment, that is, treatments should not be undertaken in futile situations 1. This QPI is intended to ensure treatment is given appropriately, and the outcome reported on and reviewed. Description: Numerator: Denominator: Proportion of patients with testicular cancer who die within 30 days of treatment for testicular cancer. Number of patients with testicular cancer who receive treatment who die within 30 days of treatment. All patients with testicular cancer undergoing treatment (i) orchidectomy, (ii) chemotherapy, (iii) radiotherapy. Exclusions: None. Target: <5% QPI 10(i) Orchidectomy QPI 10 Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 0.0% % 0 0.0% 0 FV 0.0% % 0 0.0% 0 GGC 0.0% % 0 0.0% 0 Lan 0.0% % 0 0.0% 0 WoS 0.0% % 0 0.0% 0 QPI 10(ii) Chemotherapy QPI 10 Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 0.0% % 0 0.0% 0 FV 0.0% % 0 0.0% 0 GGC 0.0% % 0 0.0% 0 Lan 0.0% % 0 0.0% 0 WoS 0.0% % 0 0.0% 0 QPI 10(iii) Radiotherapy QPI 10 Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA % 0 0.0% 0 FV NA % 0 0.0% 0 GGC % 0 0.0% 0 Lan % 0 0.0% 0 WoS 0.0% % 0 0.0% 0 (-) Data is not shown where the denominator is less than 5. There were no deaths within 30 days of treatment with (i) orchidectomy, (ii) chemotherapy or (iii) radiotherapy across the West of Scotland for patients diagnosed with testicular cancer between 01 October 2014 and 30 September 2015, resulting in a 0.0% mortality rate for all NHS Boards and treatment types. Final Published Testicular Cancer MCN Audit Report v1.0 13/06/

26 5. Conclusions Cancer audit has underpinned much of the regional development and service improvement work of the MCN and the regular reporting of activity and performance have been fundamental in assuring the quality of care delivered across the region. With the development of Quality Performance Indicators, this has now become a national programme to drive continuous improvement and ensure equity of care for patients across Scotland. West of Scotland Boards commitment in the past few years to the continuous improvement of the quality and completeness of audit data has supported this transition to national reporting. The improvements have provided accurate baseline data for the first year of Testicular Cancer QPIs from which yearly comparisons in the service provision across WoS Boards can be made. Data completeness is particularly high for Testicular Cancer QPIs with the 11 reported QPIs having all relevant data fields completed (QPIs 1 to 8, and 10(i) (iii)). It should be noted however that case ascertainment is low in some Boards and should be investigated further. Overall, results from the first year of Testicular Cancer QPI analysis are encouraging with 7 of the 11 reported QPIs being met by all four NHS Boards. It is evident however that NHS Boards have found some QPI targets challenging to meet. The audit report has identified actions relating to service provision especially with regard to timescales within the patient pathway. Specifically, the time from ultrasound diagnosis to orchidectomy and the time from orchidectomy to CT scanning require improvement to meet QPI targets. NHS Boards are asked to develop local Action/Improvement Plans in response to the findings presented in the report. A summary of actions for each NHS Board has been included within the Action Plan templates in the Appendix. Action required: Data Quality: NHS Lanarkshire and NHSGGC should compare the cases captured by audit directly with cancer registry data once this becomes available to identify whether any new cases of testicular cancer have not been included in Year 1 QPI audit. QPI 1 Radiological staging NHS Forth Valley should monitor outcome following meeting between clinical team and patient pathway co-ordinators. NHS Lanarkshire should continue to monitor improvements following the implementation of the direct referral pathway. QPI 3 Primary Orchidectomy NHSGGC should review cases where the time from ultrasound diagnosis to surgery exceeds 14 days to identify issues which may be causing delay and take appropriate action. NHS Forth Valley should monitor results locally to ensure the actions implemented with regard to GP referral have shown improved performance. QPI 6 Adjuvant treatment of stage I seminoma with carboplatin NHSGGC should review pathways to ensure all patients undergoing adjuvant single-dose carboplatin AUC7 have an EDTA carried out and commence treatment within 8 weeks of orchidectomy. Final Published Testicular Cancer MCN Audit Report v1.0 13/06/